Osteoporosis is probably the most well-known medical condition related to bone-loss.  However for those living with lupus, avascular necrosis (AVN) is also a concern – affecting approximately 10% of those living with SLE.  What is AV?  What symptoms should you look for, and how can you prevent or treat damage to your bones?  Read on to find out!

• Introduction: A Brief Guide to AVN and Lupus
• Symptoms
• Diagnosis
• Prevention and Treatment Options
• In Conclusion

Introduction:  A Brief Guide to AVN and Lupus

Avascular necrosis (AVN) – also called osteonecrosis – is the weakening and eventual “death” of bone tissue due to a lack of blood flow.  It can have many causes – damage to the bone during an accident, dislocation of a joint or high alcohol use are the most common.  However, those living with lupus have long been known to be at a higher risk for avascular necrosis as well.

Believe it or not, each of the 206 bones in the average human body is a separate organ.  Like your lungs, heart, brain or kidneys, each bone has its own blood flow. When a section of bone loses its supply of blood, it begins to get brittle, develop tiny cracks and eventually collapses – especially if it is weight bearing.

A few FAQ’s regarding AVN and Lupus:

• It is estimated that AVN can affect about 10% of those with lupus – studies range from 3% to 15%.
• Symptoms are often barely noticeable until damage is relatively advanced.
• The average diagnosis of avascular necrosis is about 8 years after the onset of SLE.
• The vast majority of the bone damage occurs on the femur – at the hip joint (75%), though it can also occur in the shoulders, knees, ankles, spine, and wrists.
• AVN can occur in multiple bones at the same time.
• Some avascular necrosis may be due directly from the autoimmune effects of lupus itself – damage to the bone or by vasculitis, inflammatory damage to the blood vessels that supply the bones, however …
• The vast majority of the damage – perhaps 90% of the time – the source of the problem is the long-term use of steroids by SLE patients!

While there is no silver bullet to stop the damage of avascular necrosis in those living with lupus, if you know its symptoms and get an early diagnosis, there are several treatment options that can help.

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Symptoms

Unfortunately, as with many types of organ damage associated with lupus, there may be few if any noticeable symptoms at first.  Over time, you might feel discomfort when you put weight on a joint and this feeling may grow over time, leading to mild pain that may increase in severity.

AVN is most commonly first felt as pain in the hip joint and can affect the way you walk.  Commonly, you might have a reduced range of motion in the hips or knees.  It may affect only one side or both.  The pain may also feel different from the pain you have felt from your lupus or from other co-morbidities, such as fibromyalgia.

 

Diagnosis

Because the symptoms associated with avascular necrosis can resemble the aches and pains caused by osteoporosis, arthritis or lupus joint inflammation, a diagnosis can be tricky.  It may take time and require you to be proactive with your healthcare providers.

After taking you medical history and physical exam, the following tests may also be necessary in order to make a definitive diagnosis:

• X-rays and/or computed tomography (CT) scans,
• Magnetic resonant imaging (MRI),
• Bone scan,
• Bone pressure test,
• Bone biopsy.

 

 Prevention and Treatment Options

There is currently no treatment that can reverse AVN, and once a diagnosis is made, it is important to treat avascular necrosis as quickly as possible because it will worsen over time and cause permanent bone loss and joint damage.  Luckily there are many things that you can do to reduce your risk for AVN, treat its symptoms and, as much as possible, limit bone loss.

How to reduce your risk for AVN:

• Reduce Alcohol intake: High alcohol consumption can increase the risk for AVN.
• Maintain low cholesterol levels: High cholesterol levels are associated with blocking the blood supply to bones – as well as other organs.
• Monitor steroid use: Since long-term use of high-dose steroids are associated with AVN, it is one more reason to work with your healthcare provider to safely lower your dosage of steroids as much as possible.
• Don’t smoke: Smoking narrows blood vessels, further reducing flow to bones.

Non-surgical Treatments:

• Medications:
  • Nonsteroidal anti-inflammatory drugs (such as Advil, Naproxen, Motrin, etc.). However, these may not be appropriate if kidney function has been compromised.
  • Osteoporosis medications, such as Fosamax.
  • Cholesterol lowering medication such as statins, if necessary.
• Rest and sleep, which can reduce the pressure on the affected bone and give them time to heal.
• Electrical stimulation has been used to encourage bone growth.
• Exercise moderately and only as recommended by a physical therapist or other health professional.  If done correctly, it can also help encourage bone growth and maintain the range of motion of affected joints.

Surgical Treatments:

Unfortunately, since many will not know they have avascular necrosis until it has caused significant damage, surgery may be recommended.  These include:

• Joint Replacement: This surgery replaces damaged bone and joints with metal and ceramic prosthetics.  It is estimated that about 10% of all hip replacement surgeries are due to AVN.
• Core Decomposition: This procedure removes part of the inner layer of bone to help stimulate the development of new bone tissue and blood vessels.
• Bone Grafts: This replaces the affected section of bone with bone from another part of your body.
• Stem Cell Therapy: This is a relatively new treatment for AVN and involves taking the patient’s own bone marrow stem cells from healthy bone and transplanting them to the affected bone.

In Conclusion

Avascular necrosis is a serious concern for those living with SLE. However, it does not affect everyone and you can limit your risks for AVN by doing many of the same things you are already doing for your lupus:

• Maintain a healthy lifestyle with a good diet and moderate exercise;
• Stick to your treatment plan and consistently take your medications;
• Schedule and keep regular medical appointments;
• Be a good observer of your symptoms and how they change over time;
• Finally, be a proactive member of your healthcare team, and let them know when you feel symptoms that may indicate AVN or other damage to an internal organ.

And remember, you are not alone!

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References

Bergstein, J.M., Wiens, c., Fish, A.J., Vernier, R.L., & Michael, A. (1974). Avascular necrosis of bone in systemic lupus erythematosus. The Journal of Pediatrics, 85(1), 31-35. https://doi.org/10.1016/S0022-3476(74)80281-7

Dogan, I., Kalyoncu, U., Kiliç, L., Akdogan, A., Karadag, Ö., Kiraz, S., Bilgen, S.A., & Ertenli, I. (2020). Avascular necrosis less frequently found in systemic lupus erythematosus patients with the use of alternate day corticosteroid. Turkish Journal of Medical Sciences, 50(1), 219-224. doi: 10.3906/sag-1908-182

Hussein, S., Suitner, M., Béland-Bonenefant, S., Baril-Dionne, A., Vandermeer, B., Santesso, N., Keeling, S., Pope, J.E., Fifi-Mah, A., & Bourré-Tessier, J. (2018). Monitoring of osteonecrosis in systemic lupus erythematosus: A systemic review and metaanalysis. The Journal of Rheumatology, 45(10), 1462-1476. https://doi.org/10.3899/jrheum.170837

Jokar, M.G. (2016). Avascular necrosis of bone in patients with systemic lupus erythematosus. Journal of Dental and Medical Sciences, 15(8), 130-133. https://www.iosrjournals.org/iosr-jdms/papers/Vol15-Issue%208/Version-10/X150810130133.pdf

Long, Y., Shang, S., Zhao, J., You, H., Shang, L., Li, J., Leng, X., Wang, Q., Tian, X., Li, M., & Zeng, X. (2021). Risk of osteonecrosis in systemic lupus erythematosus: An 11-year Chinese single-center cohort study. Lupus, 30(9), 1459-1468. https://doi.org/10.1177/09612033211021166

Mayo Clinic. (2022, May 17). Avascular necrosis (osteonecrosis). https://www.mayoclinic.org/diseases-conditions/avascular-necrosis/symptoms-causes/syc-20369859

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Authors: The KFL Team

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